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Zouvelou V, Petrou EM, Strataki E, Vasileiou V, Velonakis G. Pearls & Oy-sters: Thyroid-Associated Ophthalmopathy and Transient Neuromuscular Junction Disorder Due to Graves Disease. Neurology 2024; 102:e209282. [PMID: 38513158 DOI: 10.1212/wnl.0000000000209282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/22/2024] [Indexed: 03/23/2024] Open
Abstract
The concomitant presentation of thyroid-associated ophthalmopathy (TAO) and ocular myasthenia gravis is well documented. In the course of Graves disease (GD), symptomatic transient neuromuscular junction disorder may occur due to the effect of thyroid hormones at the neuromuscular synapse. Diagnostic clues are the clinical and electrophysiologic remission synchronous with restoration of euthyroidism. Furthermore, the occurrence of thymic hyperplasia in GD poses further diagnostic and therapeutic considerations. These points are discussed in the case report of a 43-year-old male patient suffering from TAO and transient neuromuscular junction disorder due to GD.
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Affiliation(s)
- Vasiliki Zouvelou
- From the 1st Neurology Department (V.Z., E.M.P., E.S.), Eginition Hospital, National and Kapodistrian University of Athens; Endocrinology Department (V.V.), Alexandra Hospital, Athens; and 2nd Department of Radiology (G.V.), Medical School, National and Kapodistrian University of Athens, Greece
| | - Elli M Petrou
- From the 1st Neurology Department (V.Z., E.M.P., E.S.), Eginition Hospital, National and Kapodistrian University of Athens; Endocrinology Department (V.V.), Alexandra Hospital, Athens; and 2nd Department of Radiology (G.V.), Medical School, National and Kapodistrian University of Athens, Greece
| | - Eleni Strataki
- From the 1st Neurology Department (V.Z., E.M.P., E.S.), Eginition Hospital, National and Kapodistrian University of Athens; Endocrinology Department (V.V.), Alexandra Hospital, Athens; and 2nd Department of Radiology (G.V.), Medical School, National and Kapodistrian University of Athens, Greece
| | - Vasiliki Vasileiou
- From the 1st Neurology Department (V.Z., E.M.P., E.S.), Eginition Hospital, National and Kapodistrian University of Athens; Endocrinology Department (V.V.), Alexandra Hospital, Athens; and 2nd Department of Radiology (G.V.), Medical School, National and Kapodistrian University of Athens, Greece
| | - Georgios Velonakis
- From the 1st Neurology Department (V.Z., E.M.P., E.S.), Eginition Hospital, National and Kapodistrian University of Athens; Endocrinology Department (V.V.), Alexandra Hospital, Athens; and 2nd Department of Radiology (G.V.), Medical School, National and Kapodistrian University of Athens, Greece
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Zammit F, Seront E. Neurological Adverse Events Related to Immune Checkpoint Inhibitors: A Practical Review. Pharmaceuticals (Basel) 2024; 17:501. [PMID: 38675461 PMCID: PMC11053462 DOI: 10.3390/ph17040501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
The increasing use of immune checkpoint inhibitors (ICI) in cancer therapy has brought attention to their associated neurotoxicities, termed neurological immune-related adverse events (n-irAEs). Despite their relatively rare incidence, n-irAEs pose a significant risk, potentially leading to severe, long-lasting disabilities or even fatal outcomes. This narrative review aims to provide a comprehensive overview of n-irAEs, focusing on their recognition and management. The review addresses a spectrum of n-irAEs, encompassing myositis, myasthenia gravis, various neuropathies, and central nervous system complications, such as encephalitis, meningitis, and demyelinating diseases. The key features of n-irAEs are emphasized in this review, including their early onset after initiation of ICIs, potential association with non-neurological irAEs and/or concurrent oncological response, the significance of ruling out other etiologies, and the expected improvement upon discontinuation of ICIs and/or immunosuppression. Furthermore, this review delves into considerations for ICI re-challenge and the intricate nature of n-irAEs within the context of pre-existing autoimmune and paraneoplastic syndromes. It underscores the importance of a multidisciplinary approach to diagnosis and treatment, highlighting the pivotal role of severity grading in guiding treatment decisions.
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Affiliation(s)
| | - Emmanuel Seront
- Institut Roi Albert II, Department of Medical Oncology, Cliniques Universitaires Saint Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium;
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Tannemaat MR, Huijbers MG, Verschuuren JJGM. Myasthenia gravis-Pathophysiology, diagnosis, and treatment. HANDBOOK OF CLINICAL NEUROLOGY 2024; 200:283-305. [PMID: 38494283 DOI: 10.1016/b978-0-12-823912-4.00026-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Myasthenia gravis (MG) is an autoimmune disease characterized by dysfunction of the neuromuscular junction resulting in skeletal muscle weakness. It is equally prevalent in males and females, but debuts at a younger age in females and at an older age in males. Ptosis, diplopia, facial bulbar weakness, and limb weakness are the most common symptoms. MG can be classified based on the presence of serum autoantibodies. Acetylcholine receptor (AChR) antibodies are found in 80%-85% of patients, muscle-specific kinase (MuSK) antibodies in 5%-8%, and <1% may have low-density lipoprotein receptor-related protein 4 (Lrp4) antibodies. Approximately 10% of patients are seronegative for antibodies binding the known disease-related antigens. In patients with AChR MG, 10%-20% have a thymoma, which is usually detected at the onset of the disease. Important differences between clinical presentation, treatment responsiveness, and disease mechanisms have been observed between these different serologic MG classes. Besides the typical clinical features and serologic testing, the diagnosis can be established with additional tests, including repetitive nerve stimulation, single fiber EMG, and the ice pack test. Treatment options for MG consist of symptomatic treatment (such as pyridostigmine), immunosuppressive treatment, or thymectomy. Despite the treatment with symptomatic drugs, steroid-sparing immunosuppressants, intravenous immunoglobulins, plasmapheresis, and thymectomy, a large proportion of patients remain chronically dependent on corticosteroids (CS). In the past decade, the number of treatment options for MG has considerably increased. Advances in the understanding of the pathophysiology have led to new treatment options targeting B or T cells, the complement cascade, the neonatal Fc receptor or cytokines. In the future, these new treatments are likely to reduce the chronic use of CS, diminish side effects, and decrease the number of patients with refractory disease.
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Affiliation(s)
- Martijn R Tannemaat
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Maartje G Huijbers
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands; Department of Human Genetics, Leiden University Medical Center, Leiden, The Netherlands
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Proudman W, Kleinig O, Lam L, Collins L, Bagster M, Gupta A, Kovoor J, Bacchi S, Slee M, Chan W. The Icepack Test in the Diagnosis of Myasthenia Gravis with Ocular Features: A Systematic Review of Diagnostic Accuracy, Technique, and Economic Utility. Semin Ophthalmol 2023; 38:679-685. [PMID: 36967601 DOI: 10.1080/08820538.2023.2194984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND The diagnosis of myasthenia gravis (MG) may be challenging and require multiple specialised testing modalities. Accessing these investigations can involve significant waiting time and costs. The bedside icepack test (IPT) has been proposed to assist with the diagnosis of MG with ocular features, and may prove an economically viable; however, there have been there is heterogeneity in the literature evaluating the IPT. OBJECTIVES A systematic review was performed examining the accuracy, described techniques, and economic implications of the IPT for the diagnosis of MG with ocular features. METHOD The databases EMBASE, PubMed, and the Cochrane Library were searched from inception to July 2022. The systematic review adhered to PRISMA guidelines. Eligibility determination was undertaken with a standardised form using appropriate inclusion criteria. The Cochrane risk of bias assessment tool for diagnostic test accuracy was employed to evaluate studies that presented the diagnostic performance of the IPT. The Johanna Briggs Institute Critical Appraisal Checklist for Economic Evaluations was used for the assessment of studies presenting economic evaluations of the IPT. RESULTS 20 articles met the specified criteria and included a total of 1264 participants. The IPT had a sensitivity ranging from 38.5% to 100%. Specificity was found to be > 95% in six studies. Excluding two outlier results of 25% and 31.3%, the lowest specificity recorded was 62.5%. The most commonly described method of evaluating the IPT involved applying ice to both eyelids and using a >2 mm change as a threshold for a positive test (evaluated with a ruler). There were no adverse effects described with the IPT. There were no studies that formally examined the economic implications of the IPT. CONCLUSIONS The IPT is a well-tolerated and readily available diagnostic tool that has an important role in the evaluation of possible MG with ocular features in specific contexts. Despite limited economic evaluation of this test, it is likely the use of the IPT may result in significant financial and time savings.
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Affiliation(s)
| | | | - Lydia Lam
- University of Adelaide, Adelaide, SA, Australia
| | - Luke Collins
- Flinders Medical Centre, Bedford Park, SA, Australia
| | | | - Aashray Gupta
- Gold Coast University Hospital, Southport, Australia
| | - Joshua Kovoor
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Stephen Bacchi
- University of Adelaide, Adelaide, SA, Australia
- Flinders Medical Centre, Bedford Park, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Mark Slee
- Flinders Medical Centre, Bedford Park, SA, Australia
| | - WengOnn Chan
- University of Adelaide, Adelaide, SA, Australia
- Royal Adelaide Hospital, Adelaide, SA, Australia
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Behbehani R. Ocular Myasthenia Gravis: A Current Overview. Eye Brain 2023; 15:1-13. [PMID: 36778719 PMCID: PMC9911903 DOI: 10.2147/eb.s389629] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/24/2023] [Indexed: 02/05/2023] Open
Abstract
Ocular myasthenia gravis (OMG) is a neuromuscular disease characterized by autoantibody production against post-synaptic proteins in the neuromuscular junction. The pathophysiological auto-immune mechanisms of myasthenia are diverse, and this is governed primarily by the type of autoantibody production. The diagnosis of OMG relies mainly on clinical assessment, the use of serological antibody assays for acetylcholine receptors (AchR), muscle-specific tyrosine kinase (MusK), and low-density lipoprotein 4 (LPR4). Other autoantibodies against post-synaptic proteins, such as cortactin and agrin, have been detected; however, their diagnostic value and pathogenic effect are not yet clearly defined. Clinical tests such as the ice test and electrophysiologic tests, particularly single-fiber electromyography, have a valuable role in diagnosis. The treatment of OMG is primarily through cholinesterase inhibitors (pyridostigmine), and steroids are frequently required in cases of ophthalmoplegia. Other immunosuppressive therapies include antimetabolites (azathioprine, mycophenolate mofetil, methotrexate) and biological agents such as B-cell depleting agents (Rituximab) and complement inhibitors (eculizumab). Evidence is scarce on the effect of immunosuppressive therapy on altering the natural course of OMG. Clinicians must be vigilant of a myasthenic syndrome in patients using immune-check inhibitors. Reliable and consistent biomarkers are required to assess disease severity and response to therapy to optimize the management of OMG. The purpose of this review is to summarize the current trends and the latest developments in diagnosing and treating OMG.
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Affiliation(s)
- Raed Behbehani
- Neuroophthalmology Unit, Ibn Sina Hospital, Kuwait City, Kuwait,Correspondence: Raed Behbehani, Ibn Sina Hospital, P.O Box 1180, Tel +965 2224 2999, Fax +965 2249 2406, Email
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Hehir MK, Li Y. Diagnosis and Management of Myasthenia Gravis. Continuum (Minneap Minn) 2022; 28:1615-1642. [PMID: 36537972 DOI: 10.1212/con.0000000000001161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW This article reviews updated diagnostic procedures and currently available treatment modalities for myasthenia gravis (MG). RECENT FINDINGS Patients with MG can be classified based on antibody status and their clinical presentation; treatment responses may differ based on disease subtypes. Improved diagnostic methods and recognition of new antigenic targets such as lipoprotein-related protein 4 have led to improved diagnostic efficiencies. Corticosteroids remain the first-line immunotherapy, but there is a trend toward minimizing their use at high doses and for long durations. Oral immunosuppressants such as mycophenolate mofetil, azathioprine, and tacrolimus remain useful. An international, multicenter randomized trial comparing thymectomy plus prednisone with prednisone alone demonstrated that thymectomy improves clinical outcomes in selected patients with nonthymomatous MG. Eculizumab, efgartigimod, and ravulizumab have recently been approved by the US Food and Drug Administration (FDA) for adult patients with generalized MG who are acetylcholine receptor-antibody positive. These drugs take advantage of novel mechanisms of action and expand treatment options for patients with MG. Data on rituximab suggest that it can be a good option, especially for patients with MG who are positive for antibodies against muscle-specific tyrosine kinase (MuSK). The number of clinical trials and drugs in development for MG is steadily increasing. SUMMARY The diagnosis of MG can generally be made from the patient's history, a neurologic examination, and laboratory and electrodiagnostic testing. Carefully selected treatment improves outcomes in MG. Additional treatment options for MG will likely be available in the near future.
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Sivakumar P, Tagare S, Kumar M. Diagnostic accuracy and clinical utility of bed side tests versus laboratory tests in the diagnosis of ocular myasthenia. Indian J Ophthalmol 2022; 70:1331-1337. [PMID: 35326049 PMCID: PMC9240561 DOI: 10.4103/ijo.ijo_2015_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Purpose To assess the diagnostic accuracy of forced eyelid closure test (FECT), ice pack test (IPT), repetitive nerve stimulation test (RNS), and acetylcholine receptor (AchR) antibody test in patients with suspected ocular myasthenia. To assess the clinical utility of AchR antibody test in predicting disease progression. Methods Retrospective cohort study of patients diagnosed with ocular myasthenia at a South-Indian neuro-ophthalmology tertiary eye clinic. Baseline characteristics; ocular myasthenia symptoms; results of FECT, IPT, RNS, and AchR antibody test; and progression time to generalized myasthenia (GM) over 36 months from the time of diagnosis were recorded and analyzed using receiver operator curve analysis, multiple logistic regression, and Kaplan-Meier survival analysis. Results FECT had a sensitivity of 96.7% (95% CI: 88.5-99.6) and a specificity of 75% (95% CI: 34.9-96.8). Combination of FECT and IPT, using the positivity of at least one test, increased the sensitivity to 98.3% (95% CI: 91-100), reducing the specificity to 50% (95% CI: 15.7-84.3), whereas using the positivity of both tests, we obtained a sensitivity of 71.7% (95% CI: 58.6-82.5) and a specificity of 100% (95% CI: 63.1-100). In the subset of patients with double negative RNS and AchR antibodies, the positive predictive value of combined FECT and IPT (double positive) was 100%. Patients who developed GM were more likely to have a positive AchR antibody test result (P = 0.001). Conclusion Combined FECT and IPT (double positive) has high diagnostic accuracy even among patients with normal RNS and negative AchR antibodies. Despite low sensitivity, AchR-antibody test has a significant predictive value in disease progression.
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Affiliation(s)
- Priya Sivakumar
- Department of Neuro Ophthalmology and Low Vision Services, Aravind Eye Care, Puducherry, India
| | | | - Mahesh Kumar
- DNB Ophthalmology, Aravind Eye Care, Madurai, Tamil Nadu, India
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8
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Oh JK, Shinder R, Hodgson NM. Ptosis With Fluctuating Diplopia. JAMA Ophthalmol 2022; 140:538-539. [PMID: 35266992 DOI: 10.1001/jamaophthalmol.2021.5629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jin Kyun Oh
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, New York.,Department of Ophthalmology, Columbia University Irving Medical Center, New York, New York
| | - Roman Shinder
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, New York.,Department of Otolaryngology, SUNY Downstate Medical Center, Brooklyn, New York
| | - Nickisa M Hodgson
- Department of Ophthalmology, SUNY Downstate Medical Center, Brooklyn, New York
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Punga AR, Maddison P, Heckmann JM, Guptill JT, Evoli A. Epidemiology, diagnostics, and biomarkers of autoimmune neuromuscular junction disorders. Lancet Neurol 2022; 21:176-188. [DOI: 10.1016/s1474-4422(21)00297-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 08/18/2021] [Accepted: 08/25/2021] [Indexed: 12/14/2022]
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Pascuzzi RM, Bodkin CL. Myasthenia Gravis and Lambert-Eaton Myasthenic Syndrome: New Developments in Diagnosis and Treatment. Neuropsychiatr Dis Treat 2022; 18:3001-3022. [PMID: 36578903 PMCID: PMC9792103 DOI: 10.2147/ndt.s296714] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
"Myasthenia Gravis is, like it or not, the neurologist's disease!" (Thomas Richards Johns II, MD Seminars in Neurology 1982). The most common disorders in clinical practice involving defective neuromuscular transmission are myasthenia gravis (MG) and Lambert-Eaton myasthenic syndrome (LEMS). The hallmark of weakness related to malfunction of the neuromuscular junction (NMJ) is variability in severity of symptoms from minute to minute and hour to hour. Fatigable weakness and fluctuation in symptoms are common in patients whether the etiology is autoimmune, paraneoplastic, genetic, or toxic. Autoimmune MG is the most common disorder of neuromuscular transmission affecting adults with an estimated prevalence of 1 in 10,000. While LEMS is comparatively rare, the unique clinical presentation, the association with cancer, and evolving treatment strategies require the neurologist to be familiar with its presentation, diagnosis, and management. In this paper we provide a summary of the meaningful recent clinical developments in the diagnosis and treatment of both MG and LEMS.
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Affiliation(s)
- Robert M Pascuzzi
- Indiana University School of Medicine, Indiana University Health, Indianapolis, IN, USA
| | - Cynthia L Bodkin
- Indiana University School of Medicine, Indiana University Health, Indianapolis, IN, USA
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Ice Pack Test in Myasthenic Ptosis as an Important Tool for Clinical Practice. J Clin Neuromuscul Dis 2021; 23:110-111. [PMID: 34808653 DOI: 10.1097/cnd.0000000000000338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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12
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Buechner S, Capone L. Ice Pack Test Eased Ptosis in a Patient Presenting with a Possible Oculomotor Nerve Schwannoma: A Case Report. Neurol Int 2021; 13:510-516. [PMID: 34698277 PMCID: PMC8544292 DOI: 10.3390/neurolint13040050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/15/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022] Open
Abstract
A 32-year-old man presented with complete third nerve palsy. Brain magnetic resonance imaging revealed a possible sporadic oculomotor nerve schwannoma in the left cavernous sinus. Interestingly, the patient’s ptosis was fluctuating and eased immediately after application of ice over his eyelid. The ice pack test (IPT) is a simple and fast method that can help diagnose myasthenia gravis (MG) in patients with ptosis. Additional diagnostic investigations (antibody assays and repetitive stimulation) excluded associated MG in the patient. Tumor treatment with Gamma Knife radiosurgery was planned. This case highlights the finding that IPT can also be positive in neurogenic (non-myasthenic) ptosis, but its usefulness in other disorders associated with muscle weakness and fatigability remains questionable.
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Kocak GS, Tütüncü M, Adatepe NU, Yerlikaya BD, Kara E, Atas A, Yener M, Oren MM. A novel diagnostic method for myasthenia gravis. Muscle Nerve 2021; 64:328-335. [PMID: 34131928 DOI: 10.1002/mus.27353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 06/08/2021] [Accepted: 06/13/2021] [Indexed: 11/07/2022]
Abstract
INTRODUCTION/AIMS Videonystagmography (VNG) which directly records eye movements using infrared video goggles with mini-cameras, is used to measure nystagmus. Our aim is to explore whether VNG can be used to detect a decrement in the extraocular muscle (EOM) activity of patients with myasthenia gravis (MG). METHODS Thirty-four patients with MG, including 13 with ocular-predominant and 21 with generalized MG, and 23 healthy controls participated. Using VNG we recorded the velocity of the eye movements of the patients as they followed a moving target. We then calculated the gain by dividing the eye movement velocity (degrees/second) by the target velocity (degrees/second). RESULTS In MG subjects, the mean initial gain (maximum gain) was 1.23 ± 0.31 (range: 0.63-2.15) for the right eye and 1.22 ± 0.37 (range; 0.60-2.28) for the left eye. The mean minimum gain was 0.11 ± 0.12 (0.01-0.58) for the right and 0.14 ± 0.5 (0.02-0.55) for the left. Due to fatigue, the movement gain was reduced by 91.7% in the right eye and 88.2% in the left eye. After reaching minimum velocity, gain remained at a minimum for a mean of 1.08 ± 0.52 (0.3-2.4) s for the right and 1.49 ± 0.85 (0.4-3.6) s for the left, before the velocity increased again. There was no fatigue-induced decrement in healthy subjects. DISCUSSION Our study documents a decrement in EOM activity recorded by VNG in patients with MG which begins to improve within 1-2 s after reaching minimum velocity, analogous to traditional low-frequency repetitive nerve stimulation testing and its U-shaped pattern. Thus, VNG may be a promising diagnostic test for MG.
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Affiliation(s)
- Goknur Selen Kocak
- Department of Neurology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Melih Tütüncü
- Department of Neurology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Nurten Uzun Adatepe
- Department of Neurology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Bengi Dolek Yerlikaya
- Department of Audiology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Eyup Kara
- Department of Audiology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Ahmet Atas
- Department of Audiology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Murat Yener
- Department of Otorhinolaryngology Istanbul, Istanbul University-Cerrahpasa, Cerrahpasa School of Medicine, Istanbul, Turkey
| | - Meryem Merve Oren
- Department of Public Health Istanbul, Istanbul University-Istanbul School of Medicine, Istanbul, Turkey
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Guidon AC, Burton LB, Chwalisz BK, Hillis J, Schaller TH, Amato AA, Betof Warner A, Brastianos PK, Cho TA, Clardy SL, Cohen JV, Dietrich J, Dougan M, Doughty CT, Dubey D, Gelfand JM, Guptill JT, Johnson DB, Juel VC, Kadish R, Kolb N, LeBoeuf NR, Linnoila J, Mammen AL, Martinez-Lage M, Mooradian MJ, Naidoo J, Neilan TG, Reardon DA, Rubin KM, Santomasso BD, Sullivan RJ, Wang N, Woodman K, Zubiri L, Louv WC, Reynolds KL. Consensus disease definitions for neurologic immune-related adverse events of immune checkpoint inhibitors. J Immunother Cancer 2021; 9:e002890. [PMID: 34281989 PMCID: PMC8291304 DOI: 10.1136/jitc-2021-002890] [Citation(s) in RCA: 81] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2021] [Indexed: 12/12/2022] Open
Abstract
Expanding the US Food and Drug Administration-approved indications for immune checkpoint inhibitors in patients with cancer has resulted in therapeutic success and immune-related adverse events (irAEs). Neurologic irAEs (irAE-Ns) have an incidence of 1%-12% and a high fatality rate relative to other irAEs. Lack of standardized disease definitions and accurate phenotyping leads to syndrome misclassification and impedes development of evidence-based treatments and translational research. The objective of this study was to develop consensus guidance for an approach to irAE-Ns including disease definitions and severity grading. A working group of four neurologists drafted irAE-N consensus guidance and definitions, which were reviewed by the multidisciplinary Neuro irAE Disease Definition Panel including oncologists and irAE experts. A modified Delphi consensus process was used, with two rounds of anonymous ratings by panelists and two meetings to discuss areas of controversy. Panelists rated content for usability, appropriateness and accuracy on 9-point scales in electronic surveys and provided free text comments. Aggregated survey responses were incorporated into revised definitions. Consensus was based on numeric ratings using the RAND/University of California Los Angeles (UCLA) Appropriateness Method with prespecified definitions. 27 panelists from 15 academic medical centers voted on a total of 53 rating scales (6 general guidance, 24 central and 18 peripheral nervous system disease definition components, 3 severity criteria and 2 clinical trial adjudication statements); of these, 77% (41/53) received first round consensus. After revisions, all items received second round consensus. Consensus definitions were achieved for seven core disorders: irMeningitis, irEncephalitis, irDemyelinating disease, irVasculitis, irNeuropathy, irNeuromuscular junction disorders and irMyopathy. For each disorder, six descriptors of diagnostic components are used: disease subtype, diagnostic certainty, severity, autoantibody association, exacerbation of pre-existing disease or de novo presentation, and presence or absence of concurrent irAE(s). These disease definitions standardize irAE-N classification. Diagnostic certainty is not always directly linked to certainty to treat as an irAE-N (ie, one might treat events in the probable or possible category). Given consensus on accuracy and usability from a representative panel group, we anticipate that the definitions will be used broadly across clinical and research settings.
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Affiliation(s)
- Amanda C Guidon
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Leeann B Burton
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Bart K Chwalisz
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - James Hillis
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Anthony A Amato
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Allison Betof Warner
- Division of Solid Tumor Oncology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Priscilla K Brastianos
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Tracey A Cho
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Justine V Cohen
- Division of Oncology, Department of Medicine, University of Pennsylvania, PA, USA
| | - Jorg Dietrich
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Dougan
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Christopher T Doughty
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuromuscular Medicine, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Divyanshu Dubey
- Departments of Neurology and Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Jeffrey T Guptill
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Douglas B Johnson
- Division of Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Vern C Juel
- Division of Neuromuscular Medicine, Duke University, Durham, NC, USA
| | - Robert Kadish
- Department of Neurology, University of Utah, Salt Lake CIty, UT, USA
| | - Noah Kolb
- Division of Neuromuscular Medicine, Department of Neurology, University of Vermont, Burlington, VT, USA
| | - Nicole R LeBoeuf
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Dermatology, Center for Cutaneous Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
| | - Jenny Linnoila
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuroimmunology and Neuroinfectious Disease, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Andrew L Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Maria Martinez-Lage
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuropathology, Department of Pathology, Massachusetts General Hospital, Boston, MA, USA
| | - Meghan J Mooradian
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jarushka Naidoo
- Medical Oncology, Department of Medicine, Beaumont Hospital Dublin and RCSI University of Health Sciences, Dublin, Ireland
- Upper Aerodigestive Division, Department of Oncology, Sidney Kimmel Comprehensive Cancer Center/Johns Hopkins University, Baltimore, MD, USA
| | - Tomas G Neilan
- Harvard Medical School, Boston, Massachusetts, USA
- Cardio-oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David A Reardon
- Harvard Medical School, Boston, Massachusetts, USA
- Center for Neuro-oncology, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Krista M Rubin
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Bianca D Santomasso
- Department of Neurology, Brain Tumor Center, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan J Sullivan
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nancy Wang
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Neuro-Oncology, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Karin Woodman
- Section of Cancer Neurology, Department of Neuro-Oncology, MD Anderson Cancer Center, Houston, TX, USA
| | - Leyre Zubiri
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Kerry L Reynolds
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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15
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Silvestri N. Reader Response: Comparison of Ice Pack Test and Single-Fiber EMG Diagnostic Accuracy in Patients Referred for Myasthenic Ptosis. Neurology 2021; 96:918. [PMID: 34032602 DOI: 10.1212/wnl.0000000000011901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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16
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Giannoccaro MP, Liguori R. Author Response: Comparison of Ice Pack Test and Single-Fiber EMG Diagnostic Accuracy in Patients Referred for Myasthenic Ptosis. Neurology 2021; 96:918-919. [PMID: 34032603 DOI: 10.1212/wnl.0000000000011902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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17
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Rousseff RT. Diagnosis of Myasthenia Gravis. J Clin Med 2021; 10:jcm10081736. [PMID: 33923771 PMCID: PMC8073361 DOI: 10.3390/jcm10081736] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
The diagnosis of autoimmune Myasthenia Gravis (MG) remains clinical and rests on the history and physical findings of fatigable, fluctuating muscle weakness in a specific distribution. Ancillary bedside tests and laboratory methods help confirm the synaptic disorder, define its type and severity, classify MG according to the causative antibodies, and assess the effect of treatment objectively. We present an update on the tests used in the diagnosis and follow-up of MG and the suggested approach for their application.
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Affiliation(s)
- Rossen T. Rousseff
- Department of Neurology, Ibn-Sina Hospital, Sabah Health Area,, Kuwait City 13115, Kuwait; ; Tel.: +359-878-417-412
- Science and Research Institute, Medical University of Pleven, 5800 Pleven, Bulgaria
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18
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Evoli A, Iorio R. Controversies in Ocular Myasthenia Gravis. Front Neurol 2020; 11:605902. [PMID: 33329368 PMCID: PMC7734350 DOI: 10.3389/fneur.2020.605902] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
Myasthenia gravis (MG) with symptoms limited to eye muscles [ocular MG (OMG)] is a rare disease. OMG incidence varies according to ethnicity and age of onset. In recent years, both an increase in incidence rate, particularly in the elderly, and a lower risk for secondary generalization may have contributed to the growing disease prevalence in Western countries. OMG should be considered in patients with painless ptosis and extrinsic ophthalmoparesis. Though asymmetric muscle involvement and symptom fluctuations are typical, in some cases, OMG can mimic isolated cranial nerve paresis, internuclear ophthalmoplegia, and conjugate gaze palsy. Diagnostic confirmation can be challenging in patients negative for anti-acetylcholine receptor and anti-muscle-specific tyrosine kinase antibodies on standard radioimmunoassay. Early treatment is aimed at relieving symptoms and at preventing disease progression to generalized MG. Despite the absence of high-level evidence, there is general agreement on the efficacy of steroids at low to moderate dosage; immunosuppressants are considered when steroid high maintenance doses are required. The role of thymectomy in non-thymoma patients is controversial. Prolonged exposure to immunosuppressive therapy has a negative impact on the health-related quality of life in a proportion of these patients. OMG is currently excluded from most of the treatments recently developed in generalized MG.
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Affiliation(s)
- Amelia Evoli
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Raffaele Iorio
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
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19
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Doughty CT, Guidon AC. Diagnostic testing for ocular myasthenia gravis: Stronger together. Neurology 2020; 95:563-564. [PMID: 32788244 DOI: 10.1212/wnl.0000000000010616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Christopher T Doughty
- From Brigham and Women's Hospital (C.T.D.); Harvard Medical School (C.T.D., A.C.G.); and Massachusetts General Hospital (A.C.G.), Boston.
| | - Amanda C Guidon
- From Brigham and Women's Hospital (C.T.D.); Harvard Medical School (C.T.D., A.C.G.); and Massachusetts General Hospital (A.C.G.), Boston
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